OBSTETRIC ANESTHESIA

Zulkifli, dr. SpAn.Mkes

Depth. Anesthesiology and Intensive
Therapy
FK Unsri/RSMH
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KEY CONCEPTS
The most common morbidities encountered in
obstetrics are severe hemorrhage and severe
preeclampsia
all obstetric patients are considered to have a
full stomach and to be at risk for pulmonary
aspiration.
Regional anesthetic techniques are preferred
for management of labor pain.
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 Using a local anestheticopioid mixture for

lumbar epidural analgesia during labor
significantly reduces drug requirements
Optimal analgesia for labor requires neural
blockade at T10L1 in the first stage of labor
and T10S4 in the second stage.
Continuous lumbar epidural analgesia is the
most versatile and most commonly employed
technique
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 dilute mixtures of a local anesthetic and an

opioid are used epidural analgesia has little if
any effect on the progress of labor
Hypotension is the most common side effect
of regional anesthetic techniques and must be
treated aggressively
Spinal or epidural anesthesia is preferred to
general anesthesia for cesarean section
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 Spinal anesthesia for cesarean section is easier

to perform and results in more rapid and
intense neural blockade than epidural
anesthesia

 the life of the mother takes priority over

delivery of the fetus
Maternal hemorrhage is one of the most
common severe morbidities complicating
obstetric anesthesia.
Pregnancy-induced hypertension describes
one of three syndromes: preeclampsia,
eclampsia, and the HELLP syndrome.
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 Common causes of postpartum hemorrhage

include uterine atony, a retained placenta,
obstetric lacerations, uterine inversion, and
use of tocolytic agents prior to delivery.
Intrauterine asphyxia during labor is the most
common cause of neonatal depression

Anesthetic Risk in Obstetric Patients

Incidence of Severe Obstetric Morbidity

Morbidity

Incidence per 1000

Severe hemorrhage

6,7

Severe preeclampsia

3,9

HELLP syndrome

0.5

Severe sepsis

0,4

Eclampsia

0,2

Uterine rupture

0,2

Anesthetic Mortality
Anesthesia accounts for approximately 23% of
maternal deaths.
32 deaths per 1,000,000 live births due to general
anesthesia
1.9 deaths per 1,000,000 live births due to
regional anesthesia.
Recent : maternal mortality from anesthesia
(about 1.6 deaths per 1,000,000 live births),
possibly due to greater use of regional anesthesia
for labor and cesarean section.
the risk greater with emergency than with
elective cesarean sections.
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General Approach to the Obstetric Patient

All patients potentially require anesthesia, whether
planned or emergent.
should be aware of the presence and relevant history
of all patients.
include age, parity, duration of the pregnancy, and
any complicating factors.
requiring anesthetic care (for labor or cesarean
section) should undergo a focused preanesthetic
evaluation.
maternal health history, anesthesia-related obstetric
history, blood pressure measurement, airway
assessment, and back examination for regional
anesthesia.
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 All women in true labor should be :

managed with intravenous fluids (usually lactated
Ringer's injection with dextrose) to prevent
dehydration.
An 18-gauge or larger intravenous catheter is
employed
Blood should be sent for typing and screening in
patients at high risk for hemorrhage or with a
borderline acceptable hematocrit.
full stomach and to be at risk for pulmonary
aspiration.
Patients at high risk for an operative delivery should
take nothing by mouth.

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 Prophylactic administration of a clear antacid

(1530 mL of 0.3 M sodium citrate orally)
every 3 h can help maintain gastric pH
greater than 2.5 and may decrease the
likelihood of severe aspiration pneumonitis.
An H2-blocking drug (ranitidine, 100150 mg
orally or 50 mg intravenously) or
metoclopramide, 10 mg orally or
intravenously, should also be considered in
high-risk patients.
The supine position should be avoided
unless a left uterine displacement device (>
15 wedge) is placed under the right hip.
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Anesthesia for Labor & Vaginal

Delivery
Psychological & Nonpharmacological
Techniques
Patient education and positive conditioning about
the birthing process

Parenteral Agents
Pudendal Nerve Block
Regional Anesthetic Techniques

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Spinal Opioid Dosages for Labor and Delivery

Agent

Intrathecal

Epidural

Morphine

0.250.5 mg

5 mg

Meperidine

1015 mg

50100 mg

Fentanyl

12.525 g

50150 g

Sufentanil

310 g

1020 g

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Local Anesthetic/Local Anesthetic

Opioid Mixtures
Lumbar Epidural Anaglesia
Although local anesthetics can be used alone,
there is rarely.
The higher concentration of local anesthetic
required (eg, bupivacaine 0.25% and ropivacaine
0.2%) can impair the parturient's ability to push
effectively as the labor progresses.
Bupivacaine or ropivacaine in concentrations of
0.06250.125% with either fentanyl 23 g/mL or
sufentanil 0.30.5 g/mL is most often used.
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 the lower the concentration of the local anesthetic the

higher the concentration of opioid that is required.
Very dilute local anesthetic mixtures (0.0625%)
generally do not produce motor blockade and may
allow some patients to ambulate ("walking" or
"mobile" epidural).
The long duration of action of bupivacaine makes it a
popular agent for labor.
Ropivacaine may be preferable because of possibly less
motor blockade and its reduced potential for
cardiotoxicity
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Epidural Activation for the First Stage

of Labor
Administer a 500- to 1000-mL intravenous
bolus of lactated Ringer's injection while the
epidural catheter is being placed.
Test for unintentional subarachnoid or
intravascular placement of the needle or
catheter

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 Give 10 mL of the local anestheticopioid

mixture in 5 mL increments
Monitor until the patient is stable
Repeat steps 3 and 4 when pain recurs until
the first stage of labor is completed

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Epidural Activation during the Second

Stage of Labor
Give a 500- to 1000-mL intravenous bolus of lactated
Ringer's injection.
If the patient does not already have a catheter in
place, identify the epidural space while the patient is
in a sitting position.
A patient who already has an epidural catheter in
place should be placed in a semiupright or sitting
position prior to injection.

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 Give a 3-mL test dose of local anesthetic (eg,

lidocaine 1.5%) with 1:200,000 epinephrine. Again
the injection should be between contractions.
give 1015 mL of additional local anestheticopioid
mixture at a rate not faster than 5 mL every 12 min.
Administer oxygen by face mask and lay the patient
supine with left uterine displacement and monitor

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Management of Complications

Hypotension
Unintentional Intravascular Injections
Unintentional Intrathecal Injection
Postdural Puncture Headache (PDPH)
Maternal Fever

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Combined Spinal & Epidural (CSE)

Analgesia
particularly benefit patients with severe pain early
in labor and those who receive
analgesia/anesthesia just prior to delivery.
Intrathecal opioid and local anesthetic are injected
and an epidural catheter is left in place.
The intrathecal drugs provide almost immediate
pain control and have minimal effects on the early
progress of labor, whereas the epidural catheter
provides a route for subsequent analgesia for labor
and delivery or anesthesia for cesarean section.
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 Addition of small doses of local anesthetic

agents to intrathecal opioid injection greatly
potentiates their analgesia and can
significantly reduce opioid requirements.
inject 2.5 mg of preservative-free bupivacaine
or 34 mg of ropivacaine with intrathecal
opioids for analgesia in the first stage of labor.

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 Intrathecal doses for CSE are fentanyl 45 g or

sufentanil 23 g.
Addition of 0.1 mg of epinephrine prolongs the
analgesia with such mixtures but not for
intrathecal opioids alone. Some studies suggest
that CSE techniques may be associated with
greater patient satisfaction than epidural
analgesia alone.
A 24- to 27-gauge pencil-point spinal needle
(Whitacre, Sprotte, or Gertie Marx) is used to
minimize the incidence of PDPH.
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Spinal Anesthesia (ILA)

given just prior to delivery
Also known as saddle blockprovides profound
anesthesia for operative vaginal delivery.
A 500- to 1000-mL fluid bolus is given prior to the
procedure, which is performed with the patient
in the sitting position.
Use of a 22-gauge or smaller, pencil-point spinal
needle (Whitacre, Sprotte, or Gertie Marx)
decreases the likelihood of PDPH.
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 Hyperbaric tetracaine (34 mg), bupivacaine (67 mg),

or lidocaine (2040 mg) usually provides excellent
perineal anesthesia.
Addition of fentanyl 12.525 g or sufentanil 57.5 g
significantly potentiates the block. A T10 sensory level
can be obtained with slightly larger amounts of local
anesthetic.
The intrathecal injection should be given slowly
between contractions to minimize excessive cephalad
spread.
Three minutes after injection, the patient is placed in
the lithotomy position with left uterine displacement.
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Anesthesia for Cesarean Section

Major Indications for Cesarean Section
Labor unsafe for mother and fetus

Increased risk of uterine rupture

Previous classic cesarean section

Previous extensive myomectomy or

uterine reconstruction
Increased risk of maternal
hemorrhage
Central or partial placenta previa

Abruptio placentae

Dystocia

Abnormal fetopelvic relations

Immediate or emergent delivery

necessary
Fetal distress

Fetopelvic disproportion

Umbilical cord prolapse

Abnormal fetal presentation

Maternal hemorrhage

Transverse or oblique lie

Breech presentation

Dysfunctional uterine activity

Amnionitis

Genital herpes with ruptured

membranes
Impending maternal death

Previous vaginal reconstruction

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REGIONAL ANESTHESIA
Cesarean section requires a T4 sensory level.
receive a 1000- to 1500-mL bolus of lactated
Ringer's injection prior to neural blockade.
Crystalloid boluses do not consistently prevent
hypotension but can be helpful in some patients.
Smaller volumes (250500 mL) of colloid
solutions more effective.
supplemental oxygen (4050%) is given
blood pressure is measured every 12 min until it
stabilizes.
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 Intravenous ephedrine, 10 mg, should be used to

maintain systolic blood pressure > 100 mm Hg.
Hypotension following epidural anesthesia
typically has a slower onset.
Slight Trendelenburg positioning facilitates
achieving a T4 sensory level and may also help
prevent severe hypotension.
Extreme degrees of Trendelenburg interfere with
pulmonary gas exchange.
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ADVANTAGES
REGIONAL ANESTHESIA
less neonatal exposure to
drugs
decreased risk of maternal
pulmonary aspiration
awake mother at the birth
of her child
using spinal opioids for
postoperative pain relief.

GENERAL ANESTHESIA
very rapid and reliable
onset
control over the airway and
ventilation
less hypotension
facilitates management in
the event of severe
hemorrhagic complications

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Regional Anesthesia
SPINAL ANESTHESIA
placed in the lateral
decubitus or sitting position
hyperbaric solution injected
Adding 12.525 g of
fentanyl or 510 g of
sufentanil
Continuous spinal
anesthesia

EPIDURAL ANESTHESIA
generally most satisfactory
excellent route for
postoperative opioid
administration
total of 1525 mL of local
anesthetic is injected slowly
in 5-mL increments

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CSE Anesthesia
CSE is combined spinal epidural analgesia.
the benefit :
rapid
Reliable
intense blockade of spinal anesthesia with the
flexibility of an epidural catheter.
The catheter can be used for postoperative analgesia.
As mentioned previously,

drugs given epidurally should be administered

and titrated carefully
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General Anesthesia Technique for

Cesarean Section
patient is placed supine
Preoxygenation is with
100% oxygen
patient is prepared and
draped for surgery
a rapid-sequence
induction with cricoid
pressure
Surgery is begun only
after placement of ETT is
confirmed

50% NO2 in O2 with up to

0.75 MAC of a volatile
agent
After the neonate and
placenta are delivered,
2030 U of oxytocin is
added
Methergine 0.2 mg
intramuscularly
aspirate gastric contents
via an oral gastric tube
reversed
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